Review of Frozen Section Results and correlation with microbiology for revision joint replacement surgery Dr R Hadden BSc MBBS SpR Histopathology Derriford.

Slides:



Advertisements
Similar presentations
Erythrocyte sedimentation rate (ESR) is a non-specific test for inflammation. It is easy to perform, widely available, Inexpensive making it a widely.
Advertisements

Specimen collection pgs , , and The lab or pathology department does countless types of examinations on every type of body.
Procalcitonin Over the past two decades, the body of literature on the clinical usefulness of procalcitonin (PCT) in adults has grown rapidly. Although.
Use of intra-operative frozen section in surgery for potential early stage ovarian malignancy September 2011 Dr Paul Cross Consultant Cellular Pathologist.
Utility of Intraoperative Frozen Section Histopathology in the Diagnosis of Periprosthetic Joint Infection by Geoffrey Tsaras, Awele Maduka-Ezeh, Carrie.
PATHOLOGIC DIAGNOSIS OF ANTIBODY-MEDIATED REJECTION (AMR) Histopathologic findings Immunopathologic findings Immunohistochemistry on paraffin sections.
Septic Arthritis: Workup. Laboratory Studies Complete blood count with differential - Often reveals leukocytosis with a left shift Erythrocyte sedimentation.
Sentinel Lymph Node procedure Intraoperative Examination Belgian Breast Meeting 14/10/2006 Daniel Faverly MD Pathology Laboratory CMP-LabPatho Centre Communautaire.
Page 1 (3 minutes) There is no picture for this page of questions Page 2 (2.5 minutes)
Level of Evidence: Level II Clin Orthop Relat Res 2008 Journal meeting Summarized R4 黃贊文 Supervised Dr. 沈世勛 Diagnosis of Infected Total Knee.
1 URINALYSIS AND BODY FLUIDS (SYNOVIAL FLUID) LECTURE ONE Dr. Essam H. Jiffri.
Combined Measurement of Synovial Fluid α-Defensin and C-Reactive Protein Levels: Highly Accurate for Diagnosing Periprosthetic Joint Infection by Carl.

Clinical Audit How to make it work Clinical Audit Department Last revised July 2009.
Hip Pain and Septic Arthritis
Microbiological Evaluation of PJIs Survey Results Lorenzo Drago IRCCS Galeazzi Institute – University of Milan.
Non-Surgical Periodontal Therapy Reduces Coronary Heart Disease Risk Markers: A Randomized Controlled Trial Bokhari SAH, Khan AA, Butt AK, Azhar M, Hanif.
The Audit Process Tahera Chaudry March Clinical audit A quality improvement process that seeks to improve patient care and outcomes through systematic.
EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION TWO Orthopaedic graft infection Author: Savita Gossain, Heart of England Foundation Trust.
Cerebrospinal fluid CSF.
Evidence-based approach in managing acute pancreatitis James Fung Department of Surgery Tseung Kwan O Hospital.
SSI: I hear the words, but are we talking about the same thing? Safer Healthcare Now! Western Node Wendy Runge, RN, BScN, CIC Infection Prevention and.
In assessing clarity you should hold the specimen against a white background in bright lighting. Physical Exam.
McGraw-Hill © 2013 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 11: The Blood System.
Pathology.
How does the immunology relate to clinical medicine?
FISHing for tricky naevi Dr Hardeep Singh Manchester BAOP 2011.
An introduction to Urinalysis as performed in the Clinical Laboratory.
Pulmonology Labs Brenda Beckett, PA-C Clinical Assessment II.
Assessing Information from Multilevel (Ordinal) Tests ROC curves and Likelihood Ratios for results other than “+” or “-” Michael A. Kohn, MD, MPP 10/4/2007.
Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Procalcitonin Use to Predict Bacterial Infection in Febrile Infants Milcent K, Faesch.
Adjuvant Radiation is Not Associated with Improved Survival in Patients with Positive Margins Following Lobectomy for Stage I & II Non-Small Cell Lung.
Interleukin-6 and other inflammatory markers in diagnosis of periprosthetic joint infection (PJI) 4 th International Conference/Orthopedics & Rheumatology.
Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age De S, et al. Arch Dis Child 2014;99:493–499.
SCH Journal Club Use of time from fever onset improves the diagnostic accuracy of C-reactive protein in identifying bacterial infections Wednesday 13 th.
REDUCING CATHETER ASSOCIATED URINARY TRACT INFECTIONS CLINICAL EXCELLENCE COMMISSION 2015 URINE COLLECTION, CULTURE and CATHETERISATION IN ACUTE SETTINGS.
Case of the Week year old male presented to the practice of Daniel Mühlemann, DC (Zürich) with an insidious onset of knee pain for the past 6 weeks.
The Natural Progression of Synovial Fluid White Blood-Cell Counts and the Percentage of Polymorphonuclear Cells After Primary Total Knee Arthroplasty by.
Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.
C - reactive protein. C - reactive protein ( CRP ) ◌ C-reactive protein was originally discovered as a substance in the serum of patients with acute inflammation.
United States Statistics on Sepsis
Outcome of CSF Analysis in Babies with Elevated CRPs but Clinically Well Dr Charlotte Davidson, Dr David Deekollu Prince Charles Hospital, Cwm Taf University.
1 CALIBRATING THE SYSTEMIC EFFECTS OF INFECTION WITH LABORATORY INVESTIGATIONS Pakistan November 2015.
DIAGNOSIS OF SEPTIC JOINT IN CHILDREN Sara Jane Shippee UW Orthopaedic Surgery, PGY-1 Seattle Children’s Hospital 11/1/2012.
CAREERS IN PATHOLOGY. PATHOLOGY Pathology is described as “the study of disease” or in other words the scientific study of the way things go wrong In.
Sepsis Care Bundle- Obstetrics Aneurin Bevan Health Board.
Perioperative Testing for Joint Infection in Patients Undergoing Revision Total Hip Arthroplasty by Mark F. Schinsky, Craig J. Della Valle, Scott M. Sporer,
Sickle Cell.
Epidemiology, general characteristics and clinical evolution
Ultrasound breast core needle biopsy
Surgical Site Infections:
CRP C- reactive protein.
SBU KANUNI SULTAN SULEYMAN TRAINING AND RESEARCH HOSPITAL
CALS Instructor Update July 14, 2016
GUIDELINES FOR PROSTHETIC JOINT INFECTION CID 2013
From: Assessment of the Accuracy of Procalcitonin to Diagnose Postoperative Infection after Cardiac Surgery Anesthes. 2007;107(2): doi: /01.anes ad.
Surgical Record Keeping Audit-Closing the Audit loop
Relationship between CMV & PU disease
Ochsner Health System- Orthopedics Division Research Studies
CRP C- reactive protein.
MT Lesson 6.
Medical Laboratory Science
Andrea Guyot Consultant Microbiologist
Allergy to Surgical Implants
Volume 3, Issue 3, Pages (September 2017)
Hematology and Coagulation Procedures
Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood-a prospective quasi-randomized controlled trial  H. Peltola,
Supervised by Dr Tim Bracey
Blood Tests.
Presentation transcript:

Review of Frozen Section Results and correlation with microbiology for revision joint replacement surgery Dr R Hadden BSc MBBS SpR Histopathology Derriford Hosptial

Revision Surgery Currently Frozen Section is considered by Orthopaedic surgeons as a vital tool in assessment of periprosthetic joint infections. Main Indications – aseptic or septic loosening Intraoperative decision on type of procedure – One stage – Two stage

Problems No agreed Gold Standard single test for diagnosing periprosthetic joint infections (PJI). International Consensus Meeting on PJI.

PJI Is Present When One of the Major Criteria Exists or Three Out of Five Minor Criteria Exist Major Criteria Two positive periprosthetic cultures with phenotypically identical organisms, OR A sinus communicating with the joint, OR Minor Criteria 1) Elevated serum C-reactive protein (CRP) AND erythrocyte sedimentation rate (ESR) 2) Elevated synovial fluid white blood cell (WBC) count OR ++change on leukocyte esterase test strip 3) Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%) 4) Positive histological analysis of periprosthetic tissue 5) A single positive culture

CriterionAcute PJI (< 90 days)Chronic PJI (> 90 days) Erythrocyte Sedimentation Rate (mm/hr) Not helpful. No threshold was determined 30 C-Reactive Protein (mg/L)10010 Synovia White Blood Cell Count (cells/μl) 10,0003,000 Synovial Polymorphonuclear (%) 9080 Leukocyte Esterase+ Or ++ Histological Analysis of Tissue > 5 neutrophils per high power field in 5 high power fields (× 400) Same as acute

Local guidelines No universally agreed gold standard (even within local team) Based on the number of polymorphs per high powered field in at least five separate fields – <5 - indicates no active infection and one stage advised – possible infection, surgeon preference along with clinical picture to dictate surgical management – >10 - indicative of active infection, requiring two stage surgical management

Recent Series Of 15 Patients If “clear operative field” and <20neuts/hpf – an infection free outcome is possible after single stage re-implantation If “poor surgical field appearances”, associated with >20neuts/hpf. 2 stage procedure done. Confirms our anecdotal evidence that positive frozen sections are macroscopically abnormal (colour/texture/odour).

Conflicting evidence Cut off 10 or 20 neuts/hpf? Do surgeons actually comply with local guidelines?

Results Reports on 50 sequential samples were reviewed The microbiology results were reviewed Correlation between the two was assessed

Frozen results 8 positive (>10 neuts/hpf) 36 Negative 6 Equivocal (5-9 neuts/hpf)

Positive FS Of the 8 positive Frozen sections: – All confirmed on paraffin – 4 grew organisms 1 on initial culture 3 on “enrichment”

Negative FS 34/36 confirmed on paraffin 2/36 cases 0 neuts on frozen, “small numbers” on later paraffin sections – Likely negative 24/36 grew organisms – 1 on culture – 23 on enrichment culture

Equivocal / Borderline 6 cases 5-9 neuts/hpf – 4 with growth on enrichment culture – 2 with no growth – All had no growth on initial culture

Results Negative frozen section Equivocal frozen section Positive frozen section Single stage operation Two stage operation 2852 Other001

Summary Negative result: 25% go on to have 2-stage procedure! Equivocal result: 50/50 split – presumably based on clinical/other test results Positive result: Good compliance (n)

Results Negative frozen section Equivocal frozen section Positive frozen section Negative Cultures Positive Cultures 3652

Results Negative frozen section Equivocal frozen section Positive frozen section Required Revision 1720 No Further Revision 12172

12% with negative FS required revision 22% with equivocal FS required revision 0% with positive FS required revision

Discussion Why do surgeons ignore negative result in 25% of cases? What is the point of FS in these cases? In equivocal FS cases, what determines the procedural outcome? Does FS really make a difference? approximate costs of £15,000.

Histology concerns: Anecdotally, positive FS correlates with macro findings. – In the Korean series, high numbers of neuts correlated with macroscopic impression. The 0-5, 5-10, 10+ criteria are arbitrary and based only on one study. Recent criteria use histology (not necessarily FS histology!) as only a minor criteria for PJI.

Microbiology concerns: Correlation with microbiology results is difficult. – Confounding factors (pre/intraop abx). – Most growth is on “enrichment culture”, we do not know the significance of these results.

Learning points / Questions Negative predictive value is published as the most important factor in intraoperative testing Why did many –ve FSs have +ve micro? ?sampling or FS poor sensitivity 25% of negative frozen sections still had a 2-stage procedure Is there another test or clinical parameter that “trumps” frozen section? Targeted or limited use should be advised (JK agrees this – reaudit needed to confirm)